HomeMy WebLinkAboutDunkin Donuts - 10/1/2019Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type: XFINITY RETAIL FOOD PERMIT
In accordance with Regulations promulgated under authority of Chapter 94, Section
305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
ANITA SCHULTZ, PRESIDENT
Whose place of business is:
BIG FISH PROMOTIONS DBA DUNKIN DONUTS @ THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
MEGHAN COLLINS, PROJECT MANAGER
Permit Expires: October 01, 2019
Food Fee: $100.00
License Number: XRF-3
BOARD OF HEALTH
MichaeCHeaCey, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name: �;q'V�fj V\ 7 f orn
Establishment Address: 8o Comft,e r G2-
Establishment Mailing Address (if different):
M oy-)s 70k-�$f's
5t, el taskDnkx� C__A` 0(0033
Establishment Telephone No:(bi o Q> (Ds b- q4c U
Applicant Name & Title: rn.Q(a a n CoWi n S ,Ira, ec� O'-)ooGLGj-P k—
Applicant Address: 80 "J
Cp1(y�rp,�rc.� �- • C�lagi�'n11a.�ry C.T'o�ao 33
Applicant Telephone No.:CB�O��33 � � 24 Hour Emergency No.:(3ic,;)6y(o _ c^ ojLo
Applicant Email: mCot `i r1S PblVNVmrin0i) Oy)- U rrY
Owner Name & Title (If different from applicant): R Y ,I�. 5.1 a-e rz
Owner Address: '�)tO CCjyY�rriGr CR- �*
Owner telephone number: (8LQ0_)W`j3-44ca W -1
Owneremail: a �,( ,vl t Z o�Fj(q fi5 rOmO\l ah . CS�YY�
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
El An Association partner.
❑ P Corporation Name Title Address
An Individual
❑ A Partnership
❑ Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name&Title: (Y)OnW i (20 t n,S Pra�,eC - rY-) C Y) a-gQ1�
Address:
Telephone No: (� _ . M� 6V 24 Hour Emergency No:
FAX: ��? (�' i 1 CJ
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
24 Hour Emergency No:
WATER SOURCE:0�i 't4t
DEP Public Water Supply No: (If applicable)
DAYS/HOURS:
Food Establishment Information
SEWAGE DI
No. of Food Employees: LO
Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file.
Ja�r�1 Colt'tn S S�ePhq►;t e \ ory,e-
Person Trained in Anti -Choking Procedures (if 25 Seats or more):
Location: ❑ Permanent Location
IYr Moblie Mobile Start Date: tQ 1114l t 01
Mobile End Dale: 10 I t , d1
Mobile Comments:
Length of Permit:
Annual
Seasonal Seasonal Dates: (p'jy' 1 V /�f t t C),
[l Temporary
Temporary Start Dale:
Temporary End Date:
Temporary Time:
Rain Date:
IM
Establishment Type:
❑,/Retail -NO FOOD PREP ( Sq. Ft) $1
U Food Service up to 100 seats
INCLUDING FOOD TRUCKS $175.00
Food Service for 101 -200 seats $250.00
Food Service for 201+ seats $300.00
❑ Supermarkets $400
Caterer $35.00
Milk R Cream $10.00
Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
Manufacture Frozen Desserts/Ice Cream
$26,00/freezer
❑ Pushcart $50.00 # of Pushcarts:
❑ Residential Kitchen $100.00
❑ Tobacco Products $160.00
❑ Retail Snack Food $60.00
Food Operations: Definitions:PHF - Potentially hazardous food (Ilmenernperalure controls required) i
Non-PHFs - non -potentially hazardous foodfno fimeRemperatun: controls required)
',(Check all that apply): RTE - ready -to -eat foods (Ex. sanr6viches, salads, muffins which need no lurtherprocessing)
❑ Sale of Commercially Pre -Packaged Non-PHFs 1 ❑ PHFCooked To Order
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service
Perishable Foods Only
Other Food Operations
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Vacuum Packaging / Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (Including bare hand
U Ice Manufactured and Packaged for
Retail Sale
❑ Juice Manufactured and Packaged for!
Retail Sale
contact alternative, time as a public healln
I control)
❑ Offers Raw Or Undercooked Food Of
Animal Origin
❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
------" -- ____ ---
❑ Offers RTE PHF in Bulk Quantities
or Reconditioned
I I To be completed by the Board of Health
—" Total Permit Fee:
Payment is due with application ❑ waived
I, the undersigned, attest to the accuracy of the Information provided in this application and affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copies of 105 CMR 690.000 and the Mideral Food Cow.
Signature of
Pursuant to MGL Ch.62C, sec.* I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid stale taxes required under law. '^ 2
Social Security Number or Federal ID: U U) --,02 Jt
Signature of Individual or Corporate Name:
TAX CERTIFICATION FORM
1 certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
60T&TrncmonS_ cYnn t col li
Signa u•e of Individual or Corporate Name Uy: Corp ate Officer Wandalory, if Applicable)
ou~�433-131
"Social Security No. (Volunlary) or Federal
identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\lJscrslsletic\Desktnp\Seou's Doeumenls\Puod Establishments- "reni ff AX CERTIFICATION FORM doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office gfInvestigations
600 Washington Street
Boston, MA 02111
wilimmass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
City/State/Zip:
Phone #: aQIS) 1033 -44'CTo
Are you an employer? Cheek the appropriate box: Business Type (required):
1.9 1 am a employer with -15 employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I not a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl, real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10,❑ Manufacturing
no employees. [No workers' comp. insuraoee required]* [In Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.] 12.0 Other��,�}��
*Any applicant that checks box III must also fill out the section below showing their workers' compensation policy information.
--If( lie corporate officers have cxcmpted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box lll.
I am an employer that is providing workers' compensation insurmhee for nhv employees. Below is the policy information.
Insurance Company Name: — �� ►� �, ��
Insurer's Address: 3 Q00 �]_c�� __jJ►V( 1--t--------_--- - __-__-___ ._ _
City/State/Zip: Sa.[A NrNeilp id
Policy b or Self -ins. Lie. it t - IvV Expiration Dale:
Attach it copy of (be workers' coin pensation policy declaration page (showing the policy number and expiration date).
I'alktre to secure coverage as required under Section 25A of MGL c. 152 can lead to file imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as welt as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DiA for insurance coverage verification.
I aio hereby certify, under the pains and pen gies of pehjhu_y that the information provided above Is true and correct,
Official use only. Do not write is this area, to be completed by city at- town official.
City nr Town:
Perm il/License #
X
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone
www.mass.gov/dia
(Policy Provisions: WCOOOOOOC)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: SEE ATTACHED ENDORSEMENT
NCCI Company Number: 20621
Company Code: 9
Suffix
LARS RENEWAL
POLICY NUMBER: 31 WE AA70VY 2
Previous Policy Number: 31 WE AA70VY
1. Named Insured and Mailing Address: BIG FISH PROMOTIONS LLC
(No., Street, Town, State, Zip Code) 80 COMMERCE ST
GLASTONBURY CT06033
FEIN Number: 06-1633731
State Identification Number(s): UIN: ME 0752035000 TIN: RI 0000000001
See Schedule of Operations if applicable
The Named Insured is: LLC
Business of Named Insured: Other Services Related to Advertising
Other workplaces not shown above: See Endorsement - WC990366
2, Policy Period: From 11/09/18 To 11109/19, ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: JP SVENDSEN AGENCY
PO BOX 3975
WOODBRIDGE CT 06525
Producer's Code: 31802564
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(877) 853-2582
Total Estimated Annual Premium: $22,328
Deposit Premium:
Policy Minimum Premium: $1,620 CT (Includes Increased Limit Min. Prem.)
Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%)
The policy is not binding unless countersigned by our authorized representative.
Countersigned by e1:e 10/30/18
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 10/30/18 Policy Expiration Date: 11/09/19
INFORMATION PAGE (Continued)
Policy Number: 31 WE AA70VY
3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states
listed here: NH SEE ENDORSEMENT - WC 99 03 67
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.
The limits of our liability under Part Two are:
Bodily injury by Accident $1,000,000 each accident
Bodily injury by Disease $1,000,000 policy limit
Bodily injury by Disease $1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here:
ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES
DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endorsements and schedule:
SEE ENDORSEMENT -WO 990368
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All information recuired below is subject to verification and change by audit.
Premium Basis
Classifications Total Estimated Rates Per Estimated
Code Number and Annual $100 of Annual
Description Remuneration Remuneration Premium
Total Standard Premium
Premium Discount
Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement
Catastrophe (Other Than Certified Acts Of Terrorism)
Other Miscellaneous State Premiums
Estimated Annual Premium (before Surcharges)
Total Estimated Surcharges
"See the attached Schedule(s) of Operations for Location and State Level Premium Information
Total Estimated Annual Premium: $22,328
Deposit Premium:
Policy Minimum Premium: $1 620 CT (Includes Increased Limit Min Prem.)
Interstate/Intrastate Identification Number: Refer to Schedule of Operations
NAICS: 541890
Labor Contractors Policy Number: SIC:
$21,711
-$616
$223
$182
$270
$21,520
$808
Form WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 10/30/18 Policy Expiration Date: 11/09/19
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Jane Doucette
From:
Meghan Collins <mcollins@bigfishpromotion.com>
Sent:
Thursday, June 13, 2019 1:47 PM
To:
Jane Doucette
Subject: RE: Food Establishment Permit Application Package.pdf
Attachments: Stephanie Tome ServeSafe.pdf, Stephanie Tome Allergen Awareness.pdf
Hi Jane,
Please see attached our managers serv-safe and allergen certificate. I will get the COI to you ASAP.
My accounts payable failed to send the check. I am so sorry for the lateness on this. We have been completely
swamped, which I know is no excuse. If the check arrives after tomorrow is that ok?
Please advise!
Thanks,
Meghan
From: Jane Doucette <Jdoucette@mansfieldma.com>
Sent: Tuesday, June 11, 2019 4:01 PM
To: Meghan Collins <mcollins@bigfishpromotion.com>
Subject: RE: Food Establishment Permit Application Package.pdf
Will need a certificate of insurance for the Workers Comp and serv-safe and 21lergen certificates.
From: Meghan Collins [mailto:mcollinsCabbigfishpromotion coml
Sent: Tuesday, June 11, 2019 3:09 PM
To: Jane Doucette
Subject: RE: Food Establishment Permit Application Package.pdf
Hi Jane,
Please see attached our health permit application. I will have accounts payable get a check in the mail to you today.
Thanks,
Meghan
From: Jane Doucette <Jdoucette@mansfieldma.com>
Sent: Monday, June 10, 2019 3:08 PM
To: Meghan Collins <mcollins@bigfishpromotion.com>
Subject: RE: Food Establishment Permit Application Package.pdf
We do not take credit card payments over the phone.
From: Meghan Collins [mailto:mcollinsObigfishpromotion.coml
Sent: Monday, June 10, 2019 2:14 PM
To: Jane Doucette
Subject: RE: Food Establishment Permit Application Package.pdf
Hi Jane,
Thank you! I am waiting on our workers comp. information and then I will get this to you ASAP. Do you take credit card
payments over the phone?
Please advise!
Thanks,
Meghan
From: Jane Doucette <Jdoucette@mansfieldma.com>
Sent: Tuesday, June 4, 2019 3:19 PM
To: Meghan Collins <mcollins@biefishpromotion.com>
Subject: Food Establishment Permit Application Package.pdf
Here is the application; we no longer send a Milk & Cream application but you will need to pay the $10.00 fee for the
permit. Thanks for the information about what will be served.
Disclaimer
The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the
recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying,
distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an Innovator in
Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in;
Security, archiving and compliance. To find out more Click Here.
Disclaimer
The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the
recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying,
distribution or taking action in relation of the contents of this information Is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in
Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in;
Security, archiving and compliance. To find out more Click Here.
1►UT -M
The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the
recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying,
distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in
Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in;
Security, archiving and compliance. To find out more Click Here.
Jane Doucette
From: Meghan Collins <mcollins@bigfishpromotion.com>
Sent: Thursday, June 13, 2019 2:21 PM
To: Jane Doucette
Cc: Amy Donovan -Palmer
Subject: RE: Food Establishment Permit Application Package.pdf
Attachments: Big Fish WC dec pages.pdf
Hi Jane,
Please see attached the Workers Comp declaration. My accounts payable has assured me that she has overnighted the
check for payment. We have a WKLB show tomorrow at the Xfinity Center. Will this be ok that you receive the check
tomorrow?
Again, my sincerest apologies for the delay on the check.
Please let me know if there's anything else we can do.
Best,
Meghan
From: Meghan Collins
Sent: Thursday, June 13, 2019 1:47 PM
To: Jane Doucette <Jdoucette@mansfieldma.com>
Subject: RE: Food Establishment Permit Application Package.pdf
Hi Jane,
Please see attached our managers serv-safe and allergen certificate. I will get the COI to you ASAP.
My accounts payable failed to send the check. I am so sorry for the lateness on this. We have been completely
swamped, which I know is no excuse. If the check arrives after tomorrow is that ok?
Please advise!
Thanks,
Meghan
From: Jane Doucette <Jdoucette@mansfieldma.com>
Sent: Tuesday, June 11, 2019 4:01 PM
To: Meghan Collins <mcollins@bigfishpromotion.com>
Subject: RE: Food Establishment Permit Application Package.pdf
Will need a certificate of insurance for the Workers Comp and serv-safe and allergen certificates.
From: Meghan Collins [mailto:mcollins(cbbigfishpromotion.com1
Sent: Tuesday, June 11, 2019 3:09 PM
To: Jane Doucette
Subject: RE: Food Establishment Permit Application Package.pdf
Hi Jane,
Please see attached our health permit application. I will have accounts payable get a check in the mail to you today.
Thanks,
Meghan
From: Jane Doucette <Duoucette@mansfieldma.com>
Sent: Monday, June 10, 2019 3:08 PM
To: Meghan Collins <mcollins@bigfishpro motion.com>
Subject: RE: Food Establishment Permit Application Package.pdf
We do not take credit card payments over the phone.
From: Meghan Collins[mailto:mcollins@bigfishpromotion.coml
Sent: Monday, June 10, 2019 2:14 PM
To: Jane Doucette
Subject: RE: Food Establishment Permit Application Package.pdf
Hi Jane,
Thank you 1 1 am waiting on our workers comp. information and then I will get this to you ASAP. Do you take credit card
payments over the phone?
Please advise!
Thanks,
Meghan
From: Jane Doucette <Joucette@mansfieldma.com>
Sent: Tuesday, June 4, 2019 3:19 PM
To: Meghan Collins <mcollins@bigfishpromotion.com>
Subject: Food Establishment Permit Application Package.pdf
Here is the application; we no longer send a Milk & Cream application but you will need to pay the $10.00 fee for the
permit. Thanks for the information about what will be served.
FITIMUTN",
The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the
recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying,
distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in
Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in;
Security, archiving and compliance. To find out more Click Here.
NIM
F]
The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the
recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying,
distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in
Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in;
Security, archiving and compliance. To find out more Click Here.
Disclaimer
The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the
recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying,
distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in
Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in;
Security, archiving and compliance. To find out more Click Here,
Jane Doucette
From: Katelyn Gonyer
Sent: Thursday, June 13, 2019 12:33 PM
To: Joseph D.Lynch
Cc: Jane Doucette
Subject: RE: Certificate of Compliance
We have the COC for 303 Branch Street. Where shall we send the original for recording?
Katelyn Merrill Gonyer
Environmental & Conservation Planner
Town of Mansfield, MA
508-851-6454
From: Joseph D. Lynch [mailto:lvnch419(&gmail.com]
Sent: Thursday, June 06, 2019 9:47 AM
To: Katelyn Gonyer
Subject: Certificate of Compliance
Katelyn,
When will the certificate be finalized. Thanks
Joe Lynch
(Policy Provisions: WCOOOOOOC)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: SEE ATTACHED ENDORSEMENT
NCCI Company Number: 20621
Company Code: 9
POLICY NUMBER: 31 WE AA7OVY
Previous Policy Number: 131 WE AA70VY
1. Named Insured and Mailing Address: BIG FISH PROMOTIONS LLC
(No., Street, Town, State, Zip Code) 80 COMMERCE ST
GLASTONBURY CT06033
FEIN Number: 06-1633731
State Identification Number(s): UIN: ME 0752035000 TIN: RI 0000000001
See Schedule of Operations if applicable
The Named Insured is: LLC
Business of Named Insured: Other Services Related to Advertising
Other workplaces not shown above: See Endorsement - WC990366
2. Policy Period: From 11/09/18 To 11/09/19 ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: JP SVENDSEN AGENCY
PO BOX 3975
WOODBRIDGE CT 06525
Producer's Code: 31802564
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(877) 863-2582
Total Estimated Annual Premium: $22,328
Deposit Premium:
Policv Minimum Premium: $1,620 CT (Includes Increased Limit Min. Prem.)
Suffix
LARSLARS RENEWAL2
2
Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%)
The policy is not binding unless countersigned by our authorized representative.
Countersigned by <Iy a If 10/30/18
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 10/30/18 Policy Expiration Date: 11/09/19
INFORMATION PAGE (Continued)
Policy Number: 31 WE AA70VY
3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states
listed here: NH SEE ENDORSEMENT - WC 99 03 67
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.
The limits of our liability under Part Two are:
Bodily injury by Accident $1,000,000 each accident
Bodily injury by Disease $1,000,000 policy limit
Bodily injury by Disease $1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here:
ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES
DESIGNATED IN ITEM 3.A, OF THE INFORMATION PAGE.
D. This policy includes these endorsements and schedule:
SEE ENDORSEMENT -WC 99 03 68
4. The premium for this policy will be determined
Plans. All information required below is sub'e
our Manuals of Rules, Classifications, Rates and Rating
Premium Basis
Classifications Total Estimated Rates Per Estimated
Code Number and Annual $100 of Annual
Description Remuneration Remuneration Premium
Total Standard Premium
Premium Discount
Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement
Catastrophe (Other Than Certified Acts Of Terrorism)
Other Miscellaneous State Premiums
Estimated Annual Premium (before Surcharges)
Total Estimated Surcharges
'See the attached Schedule(s) of Operations for Location and State Level Premium Information
Total Estimated Annual Premium: $22,328
Deposit Premium:
Policy Minimum Premium: $1 620 CT (Includes Increased Limit Min Prem.)
Interstate/Intrastate Identification Number: Refer to Schedule of Operations
NAICS: 541890
Labor Contractors Policy Number: SIC:
$21,711
-$616
$223
$182
$270
$21,520
$808
Form WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 10/30/18 Policy Expiration Date: 11/09/19
Big Fish Promotions, LLC
80 Commerce Street
Glastonbury, CT 06033
PH 860-633-4400
FX 860-633-4482
Providence, RI
June 13, 2019
To whom it may concern,
Enclosed you will find an
be
able to activate a promotion at the Xfinity Center on June 14, 2019. 1 realize this
payment is being made on the date of the event, but 1 am hopeful you will
accommodate our request to obtain this.
Could you please contact me as soon as you receive the enclosed and let me
know if you received the payment and if you require anything else? It appears
we have obtained permits from you in the past.
Thank you in advance for any assistance you can give me with regard to this
matter.
Sincerely,
KathyAnn oche
Bookkeeper
Big Fish Promotions
80 Commerce Street
Glastonbury, CT 06033
(P)860-633-4400
(F) 860-633-4482
stome@ bigfishpromotion.com
www.bigfishpromotion.com we get your brand into their hands